Why Focus on Respiratory Compromise

Changes in respiratory vital signs that accompany respiratory compromise often precede in-hospital deterioration and are associated with increased mortality due to the high likelihood of decompensation into respiratory insufficiency and failure, as well as respiratory arrest. ^1,2,3,4

Many in-hospital declines may be preventable with better respiratory monitoring and early intervention.^5,6,7

Respiratory abnormalities are the most common type of abnormalities prior to ICU admission.⁸Moreover, inpatients with respiratory insufficiency, arrest and failure originating on the general care floor have higher mortality rates, longer length of stay and ICU stays compared to other patients.⁹

Therefore, implementing better strategies for prevention, monitoring for and management ofinsufficiency, arrest and failure in patients could lead to improved patient outcomes and decreased costs.

What is respiratory insufficiency?

DEFINITION

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Respiratory insufficiency definition

Respiratory insufficiency, sometimes referred to as pulmonary insufficiency, is a condition in which the lungs fail to adequately provide oxygen and/or remove carbon dioxide from the body.¹⁰ In clinical studies evaluating the incidence or impact of respiratory insufficiency, the condition may be defined in a variety of ways, such as: a decrease in respiratory rate, a reduction in oxygen saturation of hemoglobin, or as a change in arterial blood gasses.^{11,12,13,14,15}Definitions and corresponding terms used to represent respiratory insufficiency in literature vary significantly.

ACUTE RESPIRATORY INSUFFICIENCY

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What is acute respiratory insufficiency?

There is currently no uniform and precise definition for acute respiratory insufficiency. In awake patients, the main acute respiratory insufficiency symptoms include dyspnea and impaired consciousness.¹⁶ Although further blood gas analysis allows the differentiation of hypercapnia,hypoxemia, and mixed forms, uniform threshold values and definitions for this condition are still lacking.

Despite the lack of existing guidelines, typically, acute respiratory insufficiency treatmentinvolves mechanical ventilation or initiation of extracorporeal techniques.¹⁶

CHRONIC RESPIRATORY INSUFFICIENCY

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What is chronic respiratory insufficiency?

Chronic respiratory insufficiency has been previously defined as the syndrome reflecting the plateau of physiologic compensation for serious impairment of pulmonary function, as well as the advanced stage of a heterogeneous group of respiratory diseases caused by a relative imbalance between the capacity of the respiratory muscles and the load which is placed upon them.^17,18,19 However, definitions of chronic respiratory insufficiency in the scientific literature vary.

Acute respiratory failure refers to the inability of the respiratory system to meet the oxygenation, ventilation, or metabolic requirements of the patient. Hypoxic respiratory failure (type 1) is defined as hypoxia without hypercapnia and with an arterial partial pressure of oxygen (PaO2) of <60 mmHg (<8 kPa) on room air at sea level.²⁰ Hypercapnic respiratory failure (type 2) is defined as hypoxia with an arterial partial pressure of carbon dioxide (PaCO2) of >50 mmHg (>6.5 kPa) on room air at sea level.²¹

Chronic respiratory failure typically refers to a combination of chronic hypoxemia, hypercapneaand compensatory metabolic alkalosis, resulting in chronically low oxygen levels or chronically high carbon dioxide levels.^22,23 The condition is usually caused by chronic respiratory diseases, such as chronic obstructive pulmonary disease (COPD), chronic bronchitis, and idiopathic interstitial pneumonia.

Research has demonstrated that respiratory dysfunction is a known precursor of many in-hospital adverse events, and its presence prior to the adverse events is associated with a higher rate of mortality.²⁴ Clinical studies evaluating the relationship between abnormal vital sign observations and patient outcome have shown the respiratory parameters are the most predictive of adverse outcome. ^{2-4, 25-27}

BARFORD 2012

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In a retrospective analysis of more than 6,000 emergency department patients, Barfod et al. found that respiratory abnormalities (SpO₂ and RR) were among the strongest predictor of in-hospital mortality.²

Odds ratio for in-hospital mortality for respiratory parameters at triage²

	Odds ratio for in-hospital mortality	P Value
SpO₂ 90-94	2.79	<0.0001
SpO₂ 80-89	3.73	<0.0001
SpO₂ < 80	9.01	0.002
RR 26-30 BPM	1.89	0.052
RR 31-35 BPM	4.96	0.001
RR > 35 BPM	6.41	<0.0001

Odds ratio for

in-hospital mortality

P valueSpO₂ 90-942.79<0.0001

Odds ration for in-hospital mortalityP valueSpO₂ 90-942.79<0.0001

Odds ration for in-hospital mortality	P value
SpO₂ 90-94	2.79	<0.0001
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BUIST 2004

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In a prospective study of 6,303 patients admitted to general hospital ward areas of an Australian hospital, respiratory rate was the abnormal event most predictive of in-hospital mortality.³

Independent predictors of in-hospital mortality in inpatients on the general care floor³

Event	Respiratory Parameters	Non-Respiratory Parameters
Respiratory rate < 6 BPM	14.4
Tachypnoea > 30 BPM	7.2
Decrease of consciousness		6.4
Loss of consciousness		6.4
Hypotension	2.5
SaO₂ < 90%	2.4

Event	Respiratory Parameters	Non-Respiratory Parameters
Respiratory rate < 6BPM	14.4
Tachypnoea > 30 BPM	7.2
Deacrease of consciousness		6.4
Loss of consciousness		6.4
Hypotension	2.5
SaO₂ < 90%	2.4

Event	Respiratory Parameters	Non-Respiratory Parameters
Respiratory rate < 6BPM	14.4
Tachypnoea > 30 BPM	7.2
Deacrease of consciousness		6.4
Loss of consciousness		6.4
Hypotension	2.5
SaO₂ < 90%	2.4

Event	Respiratory Parameters	Non-Respiratory Parameters
Respiratory rate < 6BPM	14.4
Tachypnoea > 30 BPM	7.2
Deacrease of consciousness		6.4
Loss of consciousness		6.4
Hypotension	2.5
SaO₂ < 90%	2.4

Event	Respiratory Parameters	Non-Respiratory Parameters
Respiratory rate < 6BPM	14.4
Tachypnoea > 30 BPM	7.2
Deacrease of consciousness		6.4
Loss of consciousness		6.4
Hypotension	2.5
SaO₂ < 90%	2.4

Event	Respiratory Parameters	Non-Respiratory Parameters
Respiratory rate < 6BPM	14.4
Tachypnoea > 30 BPM	7.2
Deacrease of consciousness		6.4
Loss of consciousness		6.4
Hypotension	2.5
SaO₂ < 90%	2.4

CHABOYER 2008

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Chaboyer et al. performed a prospective study of 300 ICU patients to determine which patient traits were most predictive of major adverse events within 72 hours of discharge. Abnormal respiratory rate (<10 or >=25) was the most significant predictor of major adverse events.⁴

Independent predictors of adverse events in the ICU⁴

	Odds Ratio for Adverse Events
Respiration rate < 10 or ≥ 25	3.22
Pulse rate > 110 BPM	2.03
High level of nursing care required	1.96

Odds ration for in-hospital mortality	P value
SpO₂ 90-94	2.79	<0.0001

Odds ration for in-hospital mortalityP valueSpO₂ 90-94

Odds ration for in-hospital mortalityP valueSpO₂ 90-942.79<0.0001

Odds Ratio for Adverse EventsRespiration rate < 10 or ≥ 253.22Pulse rate > 110 BPM2.03High level of nursin care required1.96

LJUNGGREN 2016

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In a retrospective cohort study of 96,512 adult patients who visited the emergency department of a Swedish hospital (excluding patients whose chief complaint was circulatory or respiratory arrest), deviations in respiratory rate and oxygen saturation were associated with higher odds of mortality than deviations of blood pressure and pulse rate.²⁵

Odds Ratio for Mortality for Respiratory and Cardiac Vital Sign Deviations²⁵

Risk Factor	Respiratory Parameters	Cardiac Parameters
RR < 8	18.1
SpO₂ <90 w Supplemental O₂	5.2
RR > 30	4.9
PR < 40		4.1
SpO₂ <90	3
SPB < 90		2.9
RR 26-30	2.4
SpO₂ 90-95	1.9
pr 111-120		1.9

PEBERDY 2008

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Peberdy et al. performed a retrospective review of 86,748 consecutive in-hospital cardiac arrests from 507 hospitals in the National Registry of Cardiopulmonary Resuscitation. In 42% of cases, the immediate factor preceding the event was respiratory in nature (acute respiratory insufficiency, pulmonary edema, or pulmonary embolism).²⁶

Percentage of in-hospital cardiac arrests where factor preceding the event was respiratory or non-respiratory in nature²⁶

	Respiratory Causes	Non-Respiratory Causes
Acute respiratory insufficiency	38
Hypotension		40
Acute myocardial infarction or ischemia		10
Metabolic/ electrolyte disturbance		11
Acute pulmonary edema	2
Acute pulmonary embolism	2

Odds ration for in-hospital mortalityP valueSpO₂ 90-942.79<0.0001

VOHRA 2005

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A retrospective analysis of 8,113 consecutive cardiac surgery patients to determine predictors and outcomes of recidivism in cardiac ICUs determined that respiratory failure requiring reintubation and ventilation was the primary reason for ICU recidivism.²⁷

Primary reason for ICU recidivism among 8,113 consecutive cardiac surgery patients²⁷

	Respiratory Causes	Non-Respiratory Causes
Respiratory (requiring re-intubation and ventilation	54.90%
Cardiovascular instability (including that secondary to dysthymias) and heart failure		23.10%
Re-exploration for cardiac tamponade/bleeding		7.70%
Renal failure requiring hemofiltration		6.60%
Gastro-intestinal complications requiring laparotomy		6.00%
Sepsis		1.10%
Neurological injury		0.50%

Multiple clinical studies have evaluated the utility of integrating continuous monitoring of patient respiratory status to increase early identification of respiratory compromise and improve outcome. ^7,14

Learn more about each of these studies outlining the importance of continuous monitoring.

Incidence of respiratory adverse events in moderate to deep procedural sedation is often underestimated, still reported in published clinical studies²⁸ and its consequences may, even if rarely, lead to death.²⁸

The outcomes pledge program by Medtronic will help you measure the incidence of adverse events in your own setting, with your own clinical team and your own protocols and assess the impact of capnography monitoring on the prevention of such events.

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QUACH 2008

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Quach et al. retrospectively analyzed the medical records of 100 patients who triggered medical emergency team activation due to respiratory distress. Medical emergency team activation was delayed in 50% of patients with respiratory distress, with a median duration of delay of 12 hours.⁶ Patients suffering from respiratory distress when MET team activation was delayed had significantly higher mortality.

LEE 2015

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LEE 2015

A retrospective review of the Anesthesia Closed Claims database identified 92 possible, probable, or definite opioid-induced respiratory depression claims. Ninety-seven percent of events were judged as preventable with better monitoring and response. The authors concluded that life-threatening respiratory depression develops so rapidly that intermittent checks are not sufficient.⁵

SUN 2015

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SUN 2015

Sun et al. performed a multicenter prospective analysis of 833 non-cardiac postoperative patients receiving continuous monitoring with pulse oximetry that was blinded to clinicians in order to determine the rate of undetected hypoxemia. Patients still received standard intermittent spot-check monitoring. The authors concluded that postoperative patients suffer frequent and prolonged hypoxia, which typically goes undetected by nurse-recorded intermittent SpO₂.¹⁴

	Episode > 1 Hour	Episode > 2 Hours	Episode > 6 Hours
SpO₂ < 90%	38%	27%	12%
SpO₂ < 85%	10%	6%	1%

OCHROCH 2006

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OCHROCH 2006

A 2006 study by Ochroch et al. demonstrated that the implementation of continuous pulse oximetry monitoring had beneficial effects on the timing and reasons for ICU transfer, such that there was a significant reduction in the duration of ICU stays and in the estimated cost of ICU care²⁹. In this patient cohort, the estimated cost of an ICU stay was approximately $23,000 less in the monitored patients as compared to the unmonitored patients (P=0.04).¹³

OVERDYK 2007

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OVERDYK 2007

Overdyk et al. continuously monitored postoperative patients (n=178) receiving patient-controlled analgesia on the ward who were assigned to receive morphine or meperdine by their surgeons with EtCO₂ and SpO₂ in order to determine the sensitivity of each parameter to episodes of respiratory compromise.¹³

Incidence of respiratory depression as defined by EtCO₂ and SpO₂ in postoperative patients receiving patient controlled analgesia¹¹
Incidence of patients with bradypnea (RR <10 for ≥3 minutes) as detected by EtCO₂	41%
Incidence of patients with desaturation (SpO₂ <90% for ≥3 minutes)	12%
Incidence of patients with bradypnea (RR <10 for ≥2 minutes) as detected by EtCO₂	58%
Incidence of patients with desaturation (SpO₂ <90% for ≥2 minutes)	21%
Percentage of desaturation events preceded by bradypnea	28%

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1. Respiratory Compromise Insitute. http://www.respiratorycompromise.org/. 2017
2. Barfod, C., Lauritzen, M. M., Danker, J. K., et al. Abnormal vital signs are strong predictors for intensive care unit admission and in-hospital mortality in adults triaged in the emergency department - a prospective cohort study. Scand J Trauma Resusc Emerg Med. 2012;20:28.
3. Buist, M., Bernard, S., Nguyen, T. V., Moore, G., & Anderson, J. Association between clinically abnormal observations and subsequent in-hospital mortality: a prospective study. Resuscitation. 2004;62(2):137-141.
4. Chaboyer, W., Thalib, L., Foster, M., Ball, C., & Richards, B. Predictors of adverse events in patients after discharge from the intensive care unit. Am J Crit Care. 2008;17(3):255-263; quiz 264.
5. Lee, L. A., Caplan, R. A., Stephens, L. S., et al. Postoperative opioid-induced respiratory depression: a closed claims analysis. Anesthesiology. 2015;122(3):659-665.
6. Quach, J. L., Downey, A. W., Haase, M., Haase-Fielitz, A., Jones, D., & Bellomo, R. Characteristics and outcomes of patients receiving a medical emergency team review for respiratory distress or hypotension. J Crit Care. 2008;23(3):325-331.
7. Taenzer, A. H., Pyke, J. B., McGrath, S. P., & Blike, G. T. Impact of pulse oximetry surveillance on rescue events and intensive care unit transfers: a before-and-after concurrence study. Anesthesiology. 2010;112(2):282-287.
8. TCTMD. Respiratory Compromise: Recognition and Management in Clinical Settings. https://www.tctmd.com/respiratory-compromise-recognition-management-clinical-settings. 2019.
9. Kelley, S., Agarwal, S., Parikh, N., Erslon, M., & Morris, P. Respiratory Insufficiency, arrest and failure among medical patients on the general care floor. Crit Care Med 2012; (12):1–328.
10. Stedman, T. L. (2008). Stedman's Medical Dictionary for the Health Professions & Nursing. Philadelphia, PA: Lippincott Williams & Wilkins.
11. Cacho, G., Perez-Calle, J. L., Barbado, A., Lledo, J. L., Ojea, R., & Fernandez-Rodriguez, C. M. Capnography is superior to pulse oximetry for the detection of respiratory depression during colonoscopy. Rev Esp Enferm Dig. 2010;102(2):86-89.
12. Hanna, M. H., Elliott, K. M., & Fung, M. Randomized, double-blind study of the analgesic efficacy of morphine-6- glucuronide versus morphine sulfate for postoperative pain in major surgery. Anesthesiology. 2005;102(4):815-821.
13. Overdyk, F. J., Carter, R., Maddox, R. R., Callura, J., Herrin, A. E., & Henriquez, C. Continuous oximetry/capnometry monitoring reveals frequent desaturation and bradypnea during patient-controlled analgesia.Anesth Analg. 2007;105(2):412-418.
14. Sun, Z., Sessler, D. I., Dalton, J. E., et al. Postoperative Hypoxemia Is Common and Persistent: A Prospective Blinded Observational Study. Anesth Analg. 2015;121(3):709-715.
15. Weingarten, T. N., Herasevich, V., McGlinch, M. C., et al. Predictors of Delayed Postoperative Respiratory Depression Assessed from Naloxone Administration. Anesth Analg. 2015;121(2):422-429.
16. Fichtner, F., Mörer, O; Laudi, S; Weber-Carstens, S; Nothacker, M; Kaisers, U. Mechanical Ventilation and Extracorporeal Membrane Oxygenation in Acute Respiratory Insufficiency. Dtsch Arztebl Int 2018; 115(50): 840-7.
17. Baum, G. Differential diagnosis of chronic respiratory insufficiency. Med Clin North Am. 1973. 57(3):623-635.
18. Vitacca, M. Telemonitoring in patients with chronic respiratory insufficiency: expectations deluded? Thorax. 2016: 71(4):299-301.
19. Goldstone, J.C., Green, M., Moxham, J. Maximum relaxation rate of the diaphragm during weaning from mechanical ventilation. Thorax 1994;49:54–60.
20. Gurka, D.P., Balk, R.A. Acute Respiratory Failure. Critical Care Medicine (Third Edition). Parillo, J.E., Dellinger, R.P. 2008, Pages 773-794 (38).
21. BMJ Best Practice. Acute respiratory failure. https://bestpractice.bmj.com/topics/en-us/853. 2019.
22. ACP Hospitalist. Chronic respiratory failure. https://acphospitalist.org/archives/2011/03/coding.htm. 2019.
23. Matsumoto, M. & Nakazato, M. Clinical applications of ghrelin for chronic respiratory diseases. Methods in Enzymology 2012: 399-407.
24. Considine J. The role of nurses in preventing adverse events related to respiratory dysfunction: literature review. J Adv Nurs 2005; 49(6):624-33.
25. Ljunggren M, Castren M, Nordberg M, et al. The association between vital signs and mortality in a retrospective cohort study of an unselected emergency department population. Scand J Trauma Resusc Emerg Med. 2016;24:21.
26. Peberdy MA, Ornato J P, Larkin GL, et al. Survival from in-hospital cardiac arrest during nights and weekends. JAMA. 2008;299(7):785-792.
27. Vohra HA, Goldsmith IR, Rosin MD, et al. The predictors and outcome of recidivism in cardiac ICUs. Eur J Cardiothorac Surg. 2005;27(3):508-511.
28. Leslie K, Allen ML, Hessian EC, Peyton PJ, Kasza J, Courtney A, et al. Safety of sedation for gastrointestinal endoscopy in a group of university-affiliated hospitals: A prospective cohort study. Br J Anaesth. 2017;118(1):90–9. https://pubmed.ncbi.nlm.nih.gov/28039246/
29. Ochroch, E. A., Russell, M. W., Hanson, W. C., 3rd, et al. The impact of continuous pulse oximetry monitoring on intensive care unit admissions from a postsurgical care floor.Anesth Analg. 2006;102(3):868-875.

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Why focus on Respiratory Compromise?